MAORI HEALTH

Kate Lagasca Mayara Assis

TABLE OF CONTENTS LO2. CRITICAL SOCIAL JUSTICE

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LO3. CURRENT EXPERIENCE

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LO4. APPLICATION OF TE TIRITI TO HEALTHCARE

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LO5. APPLICATION OF TE TIRITI TO YOUR PRACTICE

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REFERENCES

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CRITICAL SOCIAL JUSTICE RACISM and HEALTH INEQUITIES In Aotearoa’s healthcare system, we are able to see the poorer than average health outcomes that Māori individuals receive. Poor health outcomes for Māori continues to be a problem as factors such as racism continue to be present in the healthcare system in Aotearoa (The Health Quality & Safety Commission, 2019). Racism towards Māori continues to be seen through the many inequities in health outcomes, in all stages of life from maternity and birth to old age. The Healthcare system continues to not uphold the rights of Māori which consequently leads to these health inequities. Institutional racism is how this treatment of Māori individuals has been described in the healthcare system, as it plays a role in determining the inequities that arise from deeply rooted societal structures and ideas (Talamaivao et al. 2020). The Health Quality & Safety Commission (2019) described that this Institutional racism happens when all individuals within the system involved in any form of decision making, makes these decisions that consequently disadvantage a particular group compared to another. Inequities have started as early as maternity and birth with Māori mothers and their babies. They have higher mortality rates than non-Māori mothers and their babies. There are fewer Māori mothers registered with a lead maternity career than non-Māori mothers, with a 17% gap still present. It has been shown that Māori mothers faced barriers and lack of communication when navigating the healthcare system when trying to gain access to a lead maternity carer through a primary health care provider (The Health Quality & Safety Commission, 2019). Inequities also continue in childhood with Māori children’s access to oral health. There are less Māori children enrolled in oral health services than non-Māori children with a close to 20%-point difference. The impacts of this are seen with more than 50% of Māori children that are five years old having dental caries which compared to nonMāori children is a third higher (The Health Quality & Safety Commission, 2019). Evidence of these poor health outcomes is also clearly seen in New Zealand’s government response to Covid-19. It was seen that out of the 72% of the eligible Māori population only 49% were fully vaccinated by the end of the year 2021 (Megget, 2022). This is a very important statistic as Māori individuals are known to be scientifically more affected by Covid-19’s risk factors such as diabetes and obesity. In late 2021, Individuals from Māori and also Pacifica communities represented more than 70% of admissions in hospitals and also covid-19 cases. Māori individuals were not prioritised in the New Zealand government’s response to covid-19 through the vaccine rollout when they were almost our most vulnerable (Megget, 2022).

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CURRENT EXPERIENCES Despite the fact that Aotearoa has an excellent public funded healthcare system in place, social inequality still exists among the Indigenous people of New Zealand, the Māori (Graham & Masters-Awatere, 2020). Before colonisation, Māori had developed their own healthcare systems which were correlated to their spiritual and personal health beliefs, to benefit their colony and their environment. However, colonisation disrupted these by imposing new healthcare systems including hospitals which serve Pakeha (Graham and Masters-Awatere, 2020).

“THEY INTERROGATE YOU BECAUSE YOU’RE BROWN” (Graham and MastersAwatere, 2020, p.197). One barrier that estranged Māori and their whānau to healthcare is the organisational structure. Many Maori said they felt racially discriminated in the healthcare system, which had a negative impact on their experience and relationships with physicians (Walker et al., 2022).

“EVERYTHING IS DONE IN A KIND OF WESTERN WAY” (Graham and MastersAwatere, 2020, p.197). According to Walker et al. (2022), Māori felt alienated in a health system that was not designed for them, leaving them feeling disempowered and disadvantaged) Māori patients and whānau felt that their wider spiritual and cultural practices were devalued within the health system. Māori claimed that lack of tikanga Māori in healthcare worsened negative experiences (Walker et al., 2022). Māori patients get to use traditional healing techniques such as Rongoā, karakia and mirimiri until discharge as the biomedical approach to healthcare left little room for traditional approaches (Graham & Masters-Awatere, 2020). Because of many negative stereotypes about Māori, this led them to disengage and have distrust in healthcare. Disengaging is a tactic to maintain one’s self when under attack (Graham and Masters-Awatere, 2020). Being stereotyped when seeking medical attention would hinder anyone seeking further treatment (Walker et al., 2022). This is because dominant groups have a tendency to establish negative perceptions about Māori and then

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interpret their defence strategies as a failure to take responsibility for their own health (Graham and Masters-Awatere, 2020).

“I WAS TOO FRIGHTENED TO ASK” (Graham and Masters-Awatere, 2020, p.197). The absence of relational connection contributed to negative narratives between Māori patients and health workers. According to Graham and Masters-Awatere (2020), Māori patients get frustrated by having constant changes in staff as they have to repeat themselves multiple times. This contributes to the feeling of alienation which led to inconsistencies in provided care. Because of insufficient and improper information, Māori are unable to decide what to ask for when confronted with an unclear diagnosis in a new system. The information provided to Māori patents is distressing since it was not well explained. Because of their lack of understanding, education, and fear of asking, Māori patients feel powerless and hopeless in the expectation that their needs will be provided (Walker et al., 2022). Finally, low-income whānau tended to delay seeking medical help until it became inevitable. Transportation expenses, practicalities, especially prices related with clinics, and even medications were all included in the financial costs. “That’s half of our food for the week to go to a doctor and for me, it’s not an option” (Graham and Masters-Awatere, 2020, p.197). Māori patients feel that health workers assume that they would always have whānau support available when it’s not. Whānau members were also financially and timewise burdened by the provision of transportation and healthcare visits (Graham and Masters-Awatere, 2020).

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APPLICATION OF TE TIRITI TO HEALTHCARE All life is sacred in the Māori worldview, and everything has a mauri, therefore everything is interdependent and interconnected. The spiritual dimension of health is a necessary component of Māori health. Spirituality honours and fosters kinship ties to extended family, ancestral land, culture, and ancestry. Failure to include spirituality in health promotion activities disregards many of Māori's most important beliefs and concerns (Berghan et al., 2017). In the first reaction to covid-19, Because no single programme can reach everyone, Māori were vulnerable and at risk. Māori and their whānau continue to be concerned about receiving insufficient centrally managed support. While macro-level government policy decisions were a wise facilitator of positive Māori outcomes, Mcmeeking and Savage (2020) argue that Māori mobilisation and self-responsibility were the main aspects that empowered and helped the Māori. During lockdown, many iwi, hapu and community organisations as well as service providers mobilised to respond to the immediate needs of whānau (McAllister et al., 2021).

“Addressing Māori wellbeing through a Te Ao Māori lens of wairuatanga/ whanaungatanga/ hinengaro (uplifting spirits/ togetherness/ mental wellbeing, Ngāti Kahungunu iwi delivered…as more ordinary food parcels, to help lift the spirits of whānau and children especially in lockdown over Easter.” (McAllister et al., 2021, p.22).

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Wairuatanga is an important part of Māori culture and well-being. It has been improved In tikanga (culture) expressions and practise. Wairuatanga was also demonstrated in the first covid response by Māori networks' ability to provide uplifting and communal material, as well as nightly karakia through video-link that anybody could attend. (McAllister et al., 2021). During Covid-19, this encouraged wairuatanga, which boosted the spirits of Māori and their whānau while also strengthening their spiritual wellness.

In Aotearoa's national response to Covid-19 the plan that was proposed for Māori was one that aimed to support the Crowns in upholding its obligation to Te Tiriti o Waitangi. Investments in support of Māori health were made, with the ministry of health working directly with Tumu Whakarae who are general managers for Māori Health on district health boards. These investments were allocated to different resources and outreach support, aiming to protect Māori and their wider communities. Outreach services was one of the resources that was provided funding in the Māori-focused funding with $8 million being allocated (Ministry of Health, 2020). Whānau Ora was also allocated a funding of $14.3 million. This essential resource provides a whānau focused and centred approach to wellbeing, all while putting whānau at the centre of their own decision making (Whānau Ora, n.d.). This demonstrates tikanga through whānau not only being able to but also encouraged to make decisions regarding their wellbeing, through being able to honour the values, practices and rules of the Moari worldview (Te One & Clifford, 2021). Tikanga was also applied through the adaptation of tikanga to be able to uphold cultural practices through online karakia and tangihanga. These initiatives allowed the needs of Moari and whānau to be met, as these cultural practices are important to the spiritual and emotional wellbeing of Maori. With these cultural practices normally being in person, tikanga was applied through its ability to adjust in light of changes in contexts, environments and circumstances like covid-19. Tikanga also provided Maori individuals with the guidance that was needed to know how to act and why to act in response to Covid-19 (Te One & Clifford, 2021).

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APPLICATION OF TE TIRITI TO YOUR PRACTICE Mayara: Ensuring kawa Whakaruruhau for Māori patients and whānau will be done through adaptations within practice. Kawa Whakaruruhau is extremely vital in practice as it is the concept of cultural safety (Ramsden, 1990). Kawa Whakaruruhau is important as it aids in optimal healthcare for Māori. Being able to provide culturally safe care will consequently help to combat some of the existing health inequities for Māori. Health professionals need to be able to ensure Kawa Whakaruruhau is met in all practice as this allows Māori to feel safe, understood and as a result leading to Māori feeling as though they can access the healthcare available to them. Adaptations like that of protecting tikanga ensure Kawa Whakaruruhau. This would consist of protecting and upholding Māori values, practices, culture and behaviours in health practice to in turn provide culturally safe care. Understanding concepts like Hauora when dealing with Māori patients and whānau and adapting this into their care is important, as this would enable them to be cared for with the Māori worldview of holistic health. Taking into consideration beyond just biological factors and seeing all dimensions of Māori and whānau (Te One & Clifford, 2021). Ensuring that the level of understanding of the inequities for Māori within the healthcare system and why these inequities are present, is also an adaptation needed to ensure Kawa Whakaruruhau. This is significant as understanding and acknowledging Māori history leads to understanding Māori in today’s context and why there is a need to ensure kawa Whakaruruhau in every practice. This starts with becoming knowledgeable of New Zealand and what occurred in its colonial history for Māori. This will allow for a more sensitive and non-judgmental approach for Māori patients and whānau, as there will be an understanding of the generational impacts that have led to the inequities. This will in turn ensure Whakaruruhau through being able to provide a safe space for Māori individuals that is inclusive and accepting (Ramsden, 1990).

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Kate: According to the Nursing Council of New Zealand (2020), kawa whakaruruhau is focused on cultural safety. Understanding the importance of keeping Māori informed ensures kawa whakaruruhau as it empowers them to make decisions about their health. I'll also make sure to include Māori perspectives and recognise the value of physical, spiritual, mental, and whanau wellness. For example, health practitioners should not ignore karakia (prayer) as a kind of treatment for patients' spiritual needs because it does not align with modern medicine. Another thing is to make sure to build trust and rapport with Māori patients and their whānau in order for them to be able to voice out any questions they have. By doing this, patient education would be ensured. I would help Māori patients to advocate their needs in healthcare to make positive differences as well as contribute to feeling empowered. This helps Māori patients feel understood and allows them to express themselves more freely. Building and promoting relationships with Māori and their whānau would assist me as a nurse because I would have a better understanding of their cultural values, allowing me to make more accurate judgments, suggestions, diagnoses, and treatments for patients and their whānau. By practising Kawa whakaruruhau, Māori can be assured of receiving equal treatment in accordance with Te Tiriti.

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References: Berghan, G., Heather, C., Coupe, N., Doole, C., Fay, J., McCreanor, T., & Simpson., T. (2017). Te Tiriti o Waitangi-based practice in health promotion. STIR: Stop Institutional Racism Auckland, Aotearoa/New Zealand. https://trc.org.nz/sites/trc.org.nz/files/ToW%20practice%20in%20HP%20online.pdf Graham, R., & Masters-Awatere, B. (2020). Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Australian And New Zealand Journal Of Public Health, 44(3), 193-200. https://doi.org/10.1111/1753-6405.12971 McAllister, J., Neuwelt-Kearns, C., Bain, L., Turner, N., & Wynd, D. (2021). The Most Important Task: Outcomes of our collective care for low-income children in Aotearoa New Zealand in the first year of Covid-19. Cpag.org.nz. Retrieved 6 June 2022, from https://www.cpag.org.nz/assets/CPAG_2021_1st_year_of_Covid_Initial_outcomes_ of_our_collective_care_for_low_income_children_in_Aotearoa_NZ.pdf. McMeeking, S., & Savage, C. (2020). View of Maori Responses to Covid-19. Ojs.victoria.ac.nz. Retrieved 7 June 2022, from https://ojs.victoria.ac.nz/pq/article/view/6553/5729. Megget, K. (2022). How New Zealand’s covid-19 strategy failed Māori people. British Medical Journal, 376(o180), 1-2. https://doi.org/10.1136/bmj.o180 Ministry of Health. (2020). Updated COVID-19 Māori Response Action Plan. https://www.health.govt.nz/system/files/documents/publications/updated-covid19-maori-health-response-plan-jul20.pdf Ramsden, I. M. (1990). Kawa whakaruruhau: cultural safety in nursing education in Aotearoa. https://www.moh.govt.nz/NoteBook/nbbooks.nsf/0/707224BC1D4953C14C2565D7 00190AD9/$file/kawa-whakaruruhau.pdf Talamaivao, N., Harris, R., Cormack, D., Paine, S. J., & King, P. (2020). Racism and health in Aotearoa New Zealand: a systematic review of quantitative studies. New Zealand Medical Journal, 133(1521), 55-68. Te One, A., & Clifford, C. (2021). Tino Rangatiratanga and Well-being: Māori Self Determination in the Face of Covid-19. Frontiers in Sociology, 6(613340), 1-10. https://doi.org/10.3389/fsoc.2021.613340 The Health Quality & Safety Commission. (2019). A window on the quality of Aotearoa New Zealand's health care 2019. https://www.hqsc.govt.nz/assets/Our-data/Publicationsresources/Window_2019_web_final-v2.pdf

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Walker, R., Abel, S., Palmer, S., Walker, C., Heays, N., & Tipene-Leach, D. (2022). “We Need a System that’s Not Designed to Fail Māori”: Experiences of Racism Related to Kidney Transplantation in Aotearoa New Zealand. Journal Of Racial And Ethnic Health Disparities. https://doi.org/10.1007/s40615-021-01212-3

Whānau Ora. (n.d.). What we do. https://whanauora.nz/what-we-do/about/

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